NPIMap

Organization Active NPI

Amity Medical Group, Inc.

  • Federally Qualified Health Center (FQHC)
  • Charlotte, NC
National Provider Identifier
1003301300
Registry record updated Jul 31, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
AMITY MEDICAL GROUP, INC.
Practice address
6010 E W T Harris Blvd
Charlotte, NC 28215-4084
Phone
(704) 208-4134
Fax
(704) 248-8068
NPI assigned
Jun 28, 2018
Last updated
Jul 31, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 31, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dequeena Smith
Title
Credentialing
Phone
(704) 493-5326

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

6010 E W T Harris Blvd
Charlotte, NC 28215-4084

Mailing address

6010 E W T Harris Blvd
Charlotte, NC 28215-4084
Phone (704) 208-4134

Other practice location 1

10508 Park Rd Ste 130
Charlotte, NC 28210-8526
Phone (704) 208-4134

Other practice location 2

9835 Monroe Rd # B
Charlotte, NC 28270-1471
Phone (704) 208-4134

Other practice location 3

824 Lower Dallas Hwy
Dallas, NC 28034-9368
Phone (704) 208-4134

Other practice location 4

7945 N Tryon St Ste 112
Charlotte, NC 28262-3587
Phone (704) 764-1387

Other practice location 5

2300 Randolph Rd Ste A
Charlotte, NC 28207-1586
Phone (704) 764-1387

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC7 enrollments

Enrollment records 7

Enrollment IDStateProvider typePAC IDDetails
O20190823002238 NC Part B Supplier - Clinic/Group Practice 7618205980 Receives reassigned benefits from 20 practitioners
Practice locations: Charlotte, NC; Dallas, NC
O20231128003674 NC Part A Provider - Federally Qualified Health Center (FQHC) 7618205980 Practice locations: Charlotte, NC
O20240119003558 NC Part A Provider - Federally Qualified Health Center (FQHC) 7618205980 Practice locations: Charlotte, NC
O20240123000464 NC Part A Provider - Federally Qualified Health Center (FQHC) 7618205980 Practice locations: Dallas, NC
O20240502003226 NC Part A Provider - Federally Qualified Health Center (FQHC) 7618205980 Practice locations: Charlotte, NC
O20240502003371 NC Part A Provider - Federally Qualified Health Center (FQHC) 7618205980 Practice locations: Charlotte, NC
O20240502004101 NC Part A Provider - Federally Qualified Health Center (FQHC) 7618205980 Practice locations: Charlotte, NC

NPI to CCN mapping 6

The Medicare certification numbers (CCNs) connected to NPI 1003301300. Details of each certification follow.

Federally qualified health center certification: CCN B61017

Legal name
AMITY MEDICAL GROUP INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 27, 2023
Last certification
Oct 27, 2023
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
6010 E W T Harris Blvd
Charlotte, NC 28215-4084

Federally qualified health center certification: CCN B61025

Legal name
AMITY MEDICAL GROUP INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 7, 2024
Last certification
Mar 7, 2024
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
9835 Monroe Rd
Ste B
Charlotte, NC 28270-1471

Federally qualified health center certification: CCN B61026

Legal name
AMITY MEDICAL GROUP INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 2, 2024
Last certification
Jan 2, 2024
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
824 Lower Dallas Hwy
Dallas, NC 28034-9368

Federally qualified health center certification: CCN B61049

Legal name
AMITY MEDICAL GROUP INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 7, 2024
Last certification
May 7, 2024
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
7945 N Tryon St
Ste 112
Charlotte, NC 28262-3587

Federally qualified health center certification: CCN B61046

Legal name
AMITY MEDICAL GROUP INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 29, 2024
Last certification
Mar 29, 2024
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
2300 Randolph Rd
Ste a
Charlotte, NC 28207-1586

Federally qualified health center certification: CCN B61047

Legal name
AMITY MEDICAL GROUP INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 1, 2024
Last certification
Apr 1, 2024
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
4651 Charlotte Park Dr
Ste 100
Charlotte, NC 28217-3037

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D1037371Amity Medical Group824 Lower Dallas Highway, Dallas, NC 28034Certificate of waiverJun 30, 2028
34D1075060Amity Medical Group7945 North Tryon St, Ste 112, Charlotte, NC 28262Certificate of waiverOct 11, 2027
34D2060451Amity Medical Group2300 Randolph Rd, Unit a, Charlotte, NC 28207Certificate of waiverJun 17, 2027
34D2133422Amity Medical Group, Inc6010 East W T Harris Boulevard, Charlotte, NC 28215Certificate of waiverJul 11, 2027
34D2229010Amity Medical Group, Inc9835 Monroe Rd Suite B, Charlotte, NC 28270Certificate of waiverJul 5, 2027

National Provider Directory

National Provider Directory

Locations

4651 Charlotte Park Dr
Charlotte, NC 28217
Phone (704) 936-5550

4651 Charlotte Park Dr
Ste 100
Charlotte, NC 28217
Phone (704) 461-0006

6010 E Wt Harris Blvd
Ste A
Charlotte, NC 28215

7945 N Tryon St
Unit A
Charlotte, NC 28262

9835 Monroe Rd
#B
Charlotte, NC 28270
Phone (704) 208-4134

9835 Monroe Rd
Ste B
Charlotte, NC 28270
Phone (704) 208-4134

Networks

  • SC HMO

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Dequeena Smith Individual Corporate DirectorCredentialing Director Aug 21, 2021
W-2 Managing EmployeeCredentialing Director Aug 21, 2021
Operational/Managerial ControlCredentialing Director Aug 21, 2021
Corporate DirectorCredentialing Director Apr 3, 2023
W-2 Managing EmployeeCredentialing Director Apr 2, 2023
Operational/Managerial ControlCredentialing Director Apr 2, 2023
Corporate OfficerCredentialing Director Apr 2, 2023
Contracted Managing Employee Apr 3, 2023
Corporate Director Apr 3, 2023
W-2 Managing Employee Apr 3, 2023
W-2 Managing Employee Aug 21, 2021
Operational/Managerial Control Apr 3, 2023
Amity Medical Group Inc Organization, Charlotte, NC Non-profit Operational/Managerial Control Jan 1, 2018
Operational/Managerial Control Jul 1, 2022
Operational/Managerial Control Jan 1, 2024
Operational/Managerial Control May 19, 2023

Practitioners & affiliated clinicians

Practitioners 22

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 22

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1530144000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1722384000000",
    "number": "1003301300",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6010 E W T HARRIS BLVD",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282154084",
            "telephone_number": "704-208-4134",
            "fax_number": "704-248-8068"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6010 E W T HARRIS BLVD",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282154084",
            "telephone_number": "704-208-4134",
            "fax_number": "704-248-8068"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "10508 Park Rd Ste 130",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282108526",
            "country_code": "US",
            "telephone_number": "704-208-4134",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "9835 Monroe Rd # B",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282701471",
            "country_code": "US",
            "telephone_number": "704-208-4134",
            "fax_number": "704-246-8068",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "824 Lower Dallas Hwy",
            "address_purpose": "LOCATION",
            "city": "Dallas",
            "state": "NC",
            "postal_code": "280349368",
            "country_code": "US",
            "telephone_number": "704-208-4134",
            "fax_number": "704-246-8068",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "7945 N Tryon St Ste 112",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282623587",
            "country_code": "US",
            "telephone_number": "704-764-1387",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2300 Randolph Rd Ste A",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282071586",
            "country_code": "US",
            "telephone_number": "704-764-1387",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "AMITY MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-06-28",
        "last_updated": "2024-07-31",
        "certification_date": "2024-07-31",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "DEQUEENA",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "704-493-5326"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Charlotte, NC

Sources for this page

Verify at the official NPI Registry.